Utilization Review Specialist (BCBA Licensee)

Utilization Review Specialist (BCBA Licensee)

Utilizing key principles of utilization management, the Utilization Review Specialist (BCBA Licensee) performs prospective, concurrent, and retrospective reviews to determine authorization, medical necessity, and appropriateness of Applied Behavior Analysis (ABA) services. This role leverages clinical expertise in behavior analysis and evidence-based ABA practices to evaluate treatment plans, service intensity, and clinical outcomes for individuals with Autism Spectrum Disorder (ASD) and other developmental or behavioral diagnoses.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews to determine authorization, medical necessity, and appropriateness of ABA services.
• Review ABA treatment requests (initial, concurrent, and retrospective) for clinical appropriateness and benefit coverage.
• Evaluate ABA treatment plans, goals, supervision models, requested service intensity, and progress/outcomes using behavior analytic principles and evidence-based practices.
• Analyze clinical documentation, benefit plans, mandates, and medical/behavioral health policies to support determinations related to ABA services.
• Determine medical necessity and appropriateness by referencing applicable regulatory mandates, contracts/benefit information, and clinical guidelines and policies.
• Conduct research and analysis of behavioral health conditions, ABA treatment methodologies, and emerging practices within the field of behavior analysis.
• Collaborate with internal clinical leadership (e.g., medical directors) and cross-functional partners (e.g., provider and member services) to support appropriate benefit application and case decision-making.
• Coordinate as needed with internal partners and providers related to benefit determinations and case-related follow-up.
• Make appropriate referrals and contacts as needed; support members and providers with alternative care options when appropriate.
• Provide guidance to providers and internal teams regarding ABA best practices, documentation standards, and authorization requirements.
• Develop and present educational materials on ABA topics, treatment trends, and case learnings to internal stakeholders.

Requirements

• Master's Degree or higher in Behavior Analysis, Psychology, Education, or a related field
• Board Certified Behavior Analyst (BCBA) certification active and in good standing
• Active state licensure as a Behavior Analyst (if required in the practicing state) required where applicable
• 35+ years of clinical ABA experience
• Direct patient care experience delivering ABA services (e.g., in-home, center-based, school-based, community)
• Demonstrated experience developing ABA treatment plans, including:
• Functional behavior assessment/analysis (FBA/FA) and clinical documentation
• Individualized goal development and measurement strategies
• Treatment plan updates based on data and clinical progress
• Caregiver training and/or supervision/model oversight (as applicable)
• Strong written and interpersonal communication skills; ability to communicate effectively with providers and internal stakeholders
• Strong clinical assessment and analytical skills with the ability to make sound, timely determinations
• Ability to manage competing priorities and maintain organization in a fast-paced environment
• Proficiency with web-based tools and Microsoft Office (Word, Excel, PowerPoint)

Preferred Qualifications

• Prior experience in utilization management, care management, or payer-side review of ABA services
• Working knowledge of managed care and health delivery systems
• Familiarity with clinical guidelines, medical policies, accreditation, and regulatory standards (e.g., NCQA and comparable standards)
• Comfort working in a web-based systems environment and using online resources to support clinical review decisions